Provider Demographics
NPI:1063412963
Name:LARSSON, RICHARD (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:LARSSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1513
Mailing Address - Country:US
Mailing Address - Phone:716-372-0141
Mailing Address - Fax:716-372-6421
Practice Address - Street 1:12 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKLINVILLE
Practice Address - State:NY
Practice Address - Zip Code:14737-1224
Practice Address - Country:US
Practice Address - Phone:716-676-2212
Practice Address - Fax:716-676-2432
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003239363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02220780Medicaid
NYBB9663Medicare ID - Type Unspecified
NYP01457Medicare UPIN